Comparing the type of trauma and the severity of PTSD symptoms in children and adolescents
by Jess Trane
Exploring the relationship between the different types of trauma that can result in PTSD and the severity of PTSD symptoms in children and adolescents is important to creating the most developmentally appropriate and effective treatment of this disorder. Understanding what kinds of trauma are frequently linked with PTSD and how severe symptoms will help to ensure that children and adolescents receive the best possible treatment. Exposure to trauma is linked to higher prevalences of eating disorders, substance abuse, depression, anxiety, psychosis, and suicidality (Vizek Vidovic, Kuterovac-Jagodic, & Arambasic, 2000). PTSD is also linked to declines in school performance, peer relational problems, and negative effects in cognition, behavior, and personality change (Vizek-Vidovic, Kuterovac-Jagodic, & Arambasic, 2000). Developing a deeper understanding of this disorder will not only help treat these issues, but may also help treat or prevent the many comorbidities. Exposure to a natural disaster, maltreatment, and war are all types of trauma that may result in PTSD in children and adolescents. Further understanding of the relationship between these types of traumas and the severity of PTSD symptoms will help mental health practitioners to better treat this disorder.
The DSMIV-TR contains specific diagnostic criteria for PTSD. The first aspect of these criteria is that the person was exposed to a traumatic event in which they experienced, witnessed, or were confronted by an event or series of events that involved the threat of or actual death, serious injury, or threat to the physical integrity of themselves or others and felt intense fear, helplessness, or horror in response. The DSMIV-TR is careful to note that these symptoms may express themselves somewhat differently in children. Children’s response may be more centered on disorganized or agitated behavior. The criteria also requires that there be symptoms of re-experiencing the trauma, persistent avoidance of stimuli associated with the trauma and a general numbing of responsiveness, and hyperarousal. To be diagnosed with PTSD it is also required that symptoms last for over a month and cause significant distress or impairment.
Children may also experience symptoms not included in the DSMIV-TR criteria. Kaminer, Seedat, and Stein (2005) noted that children might also experience regression, new fears or the reactivation of old ones, accidents and reckless behavior, separation anxiety, and somatic issues. They also claimed that children exhibit symptoms of hyperactivity, distractibility, and increased impulsivity. There are some scales used to diagnose and assess severity in PTSD symptoms in youths based on both the DSMIV-TR criteria and the additional knowledge about the way PTSD is expressed in children. One of the most commonly used scales is the Child Post-Traumatic Stress Disorder Reaction Index (CPTSD-RI), which uses particular ranges of scores to indicate mild, moderate, severe, and very severe symptoms (Pynoos et al., 1987).
Exposure to a natural disaster, such as a hurricane, earthquake, tsunami, and other extreme force of nature, is one type of traumatic experience that can result in PTSD (Goenjian et al., 1995; Goenjian et al., 2001; Kolaitis et al., 2003; Shaw et al., 1994; Vernberg, La Greca, Silverman & Prinstein, 1996). PSTD caused by a disaster is often very complex because disasters often feature multiple traumatic aspects. During a disaster children and adolescents are exposed to the event itself, possible separation from a parent during the event or loss of a parent in light of the event, loss of another family member, possible injury to themselves or others, and possibly witnessing the death or suffering of others (Goenjian et al., 1995). Additionally, the aftermath of the event can be further traumatic. In particular, disasters in less developed countries are associated with serious public health issues (Goenjian et al., 1995). The many different issues associated with natural disasters mean that children and adolescents may experience multiple traumatic exposures.
In the aftermath of these multiple exposures, some children and adolescents develop PTSD. Kolaitis et al., (2003) looked at children living near the epicenter of the 1999 earthquake in Athens and found that 40% of their sample had CPTSD-RI scores that suggested moderate to severe symptoms. Goenjian et al.’s (1995) study on the rates of PTSD and other disorders in the aftermath of the 1988 Armenian earthquake found that two of the three neighborhoods they looked at had mean CPTSD-RI scores that indicated severe PTSD symptoms. Studies examining children in Dade County, Florida after Hurricane Andrew and adolescents in Nicaragua following Hurricane Mitch found that a significant number of their subjects reported CPTSD-RI scores that suggested moderate to very severe symptoms. (Goenjian et al., 2001; Shaw et al., 1994; Vernberg, La Greca, Silverman, & Prinstein, 1996). In a study of adolescents in Aceh affected by the 2004 tsunami found that over 60% of their sample had CPTSD-RI scores that indicated moderate to very severe symptoms. While the numbers vary across studies, a consistent trend of having a large number of children and adolescents reporting symptoms that are moderate to severe emerges. Most studies found that over 30% of their sample had moderate to severe symptoms. The high rate of subjects reporting this level of symptoms suggests that disasters are a type of trauma closely linked with more severe PTSD symptoms. A similar link may also exist in other types of traumatic events, such as war.
War is another type of trauma that can result in PTSD. There are many horrors of war that a child or adolescent could be exposed to including witnessing violence, loss of a parent, being injured, being forced to join the fighting, and more (Thabet, Abed, Vostanis, 2004). There are other aspects of war that are less often considered but may also contribute to the trauma, such as stress from seeking refugee status of trying to migrate, separation from family, socioeconomic struggles, food and water shortages, and other issues (Thabet, Abed, Vostanis, 2004). Despite the many ways war can impact children and adolescents only a limited amount of studies have been done in this area.
A study of children of Kuwait after the Gulf Crisis found that 70% of the sample reported CPTSD-RI scores that indicated moderate to severe symptoms (Nader, Pynoos, Fairbanks, & Al- Ajeel, 1993). Thabet, Abed, and Vostanis’ (2004) and Thabet & Vostanis’ (1999) studies of Palestinian refugees during conflict in the region found that a large portion of their sample had CPTSD-RI scores that indicated moderate to very severe PTSD symptoms. Bayer, Klasen, and Adam’s (2007) study of former Ugandan and Congolese child soldiers found that over 35% of their sample had CPTSD-RI scores that suggested moderate to very severe PTSD symptoms. These numbers suggest that there is a relationship between war-related trauma and severity of symptoms but more studies must be done before further conclusions can be drawn. The limited research that exists makes it difficult to identify any overarching themes and trends. More research on children and adolescents who have been exposed to war must be done to understand this relationship. In addition to war, maltreatment is another type of trauma that requires further research.
Exposure to maltreatment can also result in PTSD but there is a very limited amount of research on the relationship between maltreatment and the severity of PTSD symptoms. Wechsler-Zimring and Kearny (2011) quoted the American Psychological Association Committee on Professional Practice Standards’ definition of maltreatment, “a physical harm inflicted nonaccidentally upon (a child) by his parents of caretaker” (p. 601). Several different issues fall under the category of maltreatment, including physical abuse, sexual abuse, and neglect, making it an incredibly broad category. Maltreatment is disturbingly common. In fact, in the United States alone in 2006, 3.6 million children were the subject of a child protective services investigation and 905,000 were found to be neglected or abused (Shipman & Taussig, 2006). Research exploring the relationship between childhood maltreatment and severity of PTSD symptoms is rare. Studies largely focus on prevalence. The studies that do explore severity generally only look at severity of symptoms as mediated by other factors or explore severity in adult survivors of maltreatment. Only a limited amount of research is available that focuses on the severity of PTSD symptoms resulting from this type of trauma.
Despite the limited research in this area, the studies that have been done offer some sense of the trends in this area. Ford, Wasser, and Connor (2011) looked at a sample of children in a psychiatric outpatient setting who had experienced polyvictimization, exposure to multiple types of maltreatment and domestic based traumas, and found that polyvictimization was associated with severe parent-reported externalizing issues and clinician reported psychosocial issues and that PSTD was the only psychiatric diagnosis associated with polyvictimization. Wechsler-Zimring and Kearney’s (2011) study of adolescents who experienced different types of maltreatment found that almost 90% of their sample fit criteria for PTSD and that adolescents who had experienced physical and or sexual abuse had higher mean scores for each of the symptoms observed by the Children’s PTSD Inventory (CPTSD-I). The next highest scores were found in adolescents who had experienced neglect and physical and/or sexual abuse and the lowest scores were found in adolescents who had only experienced neglect.
The lack of research on maltreatment makes it difficult to draw conclusions about a relationship between this type of trauma and the severity of symptoms. The information that is available suggests that a relationship does indeed exist but there is not enough research available to draw any further conclusions (Ford, Wasser, & Connor, 2011; Zimring & Kearney, 2011).
There are many different limitations that are important to consider when looking over this literature. The incredible complexity of trauma makes it very difficult to study accurately. Even when the basic type of trauma is the same, such as exposure to trauma vs. a natural disaster vs. maltreatment, there are differences in levels of exposure, aspects of exposure, aftermath, and other key details that affect how someone will experience the trauma. The lack of research for particular types of trauma also limits understanding. Maltreatment is already a vague category, including several different types of trauma that include physical abuse, sexual abuse, neglect, and more, yet even then there is only a small amount of research on the severity of PTSD symptoms related to this type of trauma. War is a serious type of trauma that can have major effects on the psychological health of children and adolescents but little research has been done in this area. The research that has been done is inconsistent in several different ways.
The studies vary in many ways. First, there is a disparity in the amount of time that passed between the trauma and the study and the measurements used. Many of the measurements differ in what they focus on and how they define severe symptoms and many measurements fail to define severe at all.
Culture is also a key factor to consider because trauma is understood and may be experienced differently across cultures. These studies were conducted in many different locations across many levels of development. Culture is important to the accuracy of the measurements used as well. While the CPTSD-RI scale is very commonly used and often applied in samples outside of the United States, it was developed based on non-Hispanic White youth (Hawkins & Radcliffe, 2006). It is possible that differences in symptom expression across cultures and differences in the wording of questions in different languages affected results. The way traumatic events are viewed may also differ across cultures. This is particularly notable in the case of maltreatment; different cultures have different childrearing practices and different definitions of what constitutes maltreatment (Ferrari, 2002). Future studies should set out to address all these issues and explore the areas lacking in research.
Posttraumatic Stress Disorder is a serious issue that can have major effects on the well being on children and adolescents. There are a multitude of different types of trauma that can result in PTSD, including exposure to disasters, maltreatment, and war. Studies on natural disasters showed that significant portions of the children exposed to that type of trauma developed moderate to severe PTSD symptoms. The limited amount of studies on the severity of symptoms associated with maltreatment and war makes it harder to draw conclusions in these areas. The literature available on adolescents exposed to war is particularly sparse and well deserving of continued exploration. What little information is available suggests that there are trends in symptomatology for PTSD resulting from these types of trauma but further research must be done before themes can be accurately identified. Continuing to explore this area will further our understanding of PTSD in children and adolescents and help improve treatment.
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Jessica Trane is a senior in the Applied Psychology Program. She is currently a member of Dr. Ali and Dr. Mowry's research team. Her main research interests include empowerment, trauma, and children and adolescents. After graduating she plans to take the opportunity to gain work experience before continuing her education.